Blissborn Intake Form Please complete prior to attending Blissborn Class 1. Name(required) Email(required) Best Number to Reach You(required) Estimated Due Date(required) Occupation Birth Partner Name (Leave Blank if Single) Birth Partner Occupation Midwife/OB(required) Planned Place of Birth Home Hospital Birth Center Doula (If Applicable) What are your goals for this birth? Is there anything that would currently prevent you from having a joyful birth? Are there any considerations that I can provide to make this class more comfortable or inclusive for you or your partner? (Ex: disability awareness, pronouns, non-gendered language, etc) Participation agreement: To be successful reaching my goals, I know it is important for me to–*Practice daily. Having the birth I deserve takes preparation*Recognize that my thoughts, feelings, images, and actions have a direct effect on my life and my baby's birth. I take responsibility for my experience*Be an active participant in my hypnosis experience and see myself as a partner in the transformative nature of this process(required) I agree I do not agree I understand that the content of this series is in no way intended to be represented as medical advice nor as a prescription for medical procedures. I am aware that I should seek the advice of a midwife or doctor to answer my health or pregnancy related concerns. I agree that I will not hold the instructor or Blissborn responsible for any complications that could arise as a result of my pregnancy or birth. I understand that my childbirth educator does not guarantee a specific outcome for any student's birth(required) I agree I do not agree Submit Δ Share this:EmailPrintPinterestTwitterFacebookLike this:Like Loading...
Julie Byers 